Patient Documents

Introduction

The Documents tab on a patient’s record is where scanned and digital files travel with the patient — lab results, imaging, referral letters, and other paperwork that supports (but isn’t itself part of) the clinical narrative recorded in Vitals & Clinical Notes.

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Key Concepts

Document Types

Every uploaded document is tagged with a type, chosen from a fixed list:

Type	Typical use
Lab Result	Blood work, urinalysis, culture results
Imaging	X-ray, CT, MRI
Prescription	Medication orders written outside the system
Referral Letter	Incoming or outgoing referrals
Consent Form	Signed procedure/treatment consent
Discharge Summary	Summary from a previous facility or prior admission
Medical Certificate	Fit-to-work, fit-to-travel, etc.
Insurance Form	HMO or PhilHealth paperwork
Other	Anything not covered above — requires a free-text label

Where Documents Live

Documents are attached to the patient, not to a single encounter — a referral letter uploaded during one visit remains visible on every future visit. This is different from clinical notes and vitals, which belong to a specific encounter.

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Use Cases

Uploading a Document

1. Open the patient’s record and go to the Documents tab.
2. Click Upload Document.
3. Select the file from your workstation.
4. Choose a Document Type from the dropdown. If you choose Other, specify the type in the field that appears.
5. Optionally select a Department and add Notes.
6. Click Save.

Viewing a Document

Click View next to any document in the list to open it in a new browser tab.

Editing Document Details

Click Edit on a document to change its type, department, or notes, or to replace the underlying file. Click Save changes to confirm.

Deleting a Document

Open the document’s menu and choose Delete. This permanently removes the document from the patient’s record — there is no undo, so confirm you have the correct file before deleting.

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Reference

Permissions

Action	Permission
View documents	patient documents → view
Upload a document	patient documents → add
Edit document details	patient documents → edit
Delete a document	patient documents → delete

Privacy

Documents often contain the same sensitive information as the clinical record itself. The same RA 10173 privacy obligations that apply to patient records apply to any document attached to one.